20463 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING,RLEUFRICAI, reftmrr N 0 4 6 3
- RUII,DING DIVISION APPLICATIONIPERMIT PLUMBING.MECDANICAL - SOOOI
BUILDING PROJECT IDENTIFICATION
HUILDINGADDRESS: - - SANITARY NO. N'I'LICA'FION SUBMDTAL DATE
OWNR'SNAM (.� CON'IRA )R'S NAME,
NIC CONTROL M
C NO: ZA ITFC / I2I
CONTACT. PHONE: 131111AING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) InDG ELECT PLUMB MECH
[ FI" ❑ ❑
LICENSED CONFRACIOR'S DECLARATION QTY. ELECTRIC PEb MiT PCI:
I hereby affirm that l am licensed under ,lmn,mans ol'Chapmr 9(commencing _ JOB DESCRIPTION .
OaZ with Seetion]Oq))of Uivision3nOhe Business and Profcssinns Code.and my license i. RH tiIDENTIAI:
Won PFRMTT ISSUANCE �
[-,F in full forceand effect. ❑SFDWI, El KITCHEN REMODEL
gG U License Class Lie.#
6 U APPLIANCES-RF.SIDENTIAI. []ADDITION ❑PLUMBING RE-PITC
! H<a Date T'SDElm
F,pry ARCHITECCS DECLARATION PANELS ❑MULThUNIT El STRUCTURAL
Z O N%r z I undmland my plans shall be used as public records MODIFICATION----4 UP'1'020[1 AMPS I C1 INTERIOR ❑CUIMNF.Y REPAIR
P:4 ac Licensed Professional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
y .,]
OWNER-BUILDER DECLARATION OVLft I(KKIAMPS ❑BATH REMODEURF.PAIR ❑DEMOLITION
IY Q I hereby affirm that 1 am exempt from the Contractor's License Law for the
6 O W U ❑OTHER
X 3 L F- following reason.(Section]onsto Business and Profession Code:Any city structure coumY SIGNS IiLCCTRICAI.
W W m which requires a permit b constrvn,alma improve,demolish,ar mpaii any ermo /n
,E,i0� pdormits iswance,also requires the applicmtfnr such permino Hlea signed smtcmem SPECIAL CIRCUIT/M. —/&1.4
that he is licensed pervuanLm nbe provisions ofthe Contacmts License Law(Chaprer9 N
[++�00q (commencing with Section 7") 3 ofthe Bushossand Professions Gxle)or TEMP.M61TiRORI'O. T. SI� COMMERCIAL'
,L LL that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penxlry of POWERDIEVICILS []TENANT [I FOOD SERVICE
=gnot more than Eve hundred dollars(SSW). W IMPROVEMENT
l]Las ownerofthe property,.,my employees with wages as their sole cnmpereminn. SWIMMING POOL ELL
F will do the work,and the shoelace i%not intended or offered fnfsale(Sec.4044,Business ❑OTHER
Wend Professions Code:The Comments Li...law does at apply m en—net of OUTLITS-.7S FI
Property who builds or improves thereon.and who does such work himself or mo ugh
his own employee,Provided mat such improvements are not intended or offered for NEW RESIIF ODAI.EI:FC`F SQ IT.
sale.If,however,the building or improvement ix sold within uta,year ofeampletinn,the SQ,PC FLUOR AREA SISQ.FT.
caner-builder will have the burden of proving that he did not build or improve for put-
pose of role.). f n O
Fl 1.as owner of me property,am xclusietly contmcung with licensed coal.---as FOI U
cunstrain the project(Sec.7044.Business and Professions Cafe:)The Convucmts Li- i
cense law does not apply to an owner of property who builds or improves memon.and QTY, PLOGPERMIT FEE
rs
who contracts for such projects with a reductions)licensed puuanlin the Continuities
License Law. PERMIT IS. CE
❑ I am exempt under Sm. .B&P C for this reason
Owner - Dam ALTER-DRAIN&VENT*_ iA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PR(TITCT. CI: millk
I hereby affirm ltiw
under penalty of perjury one of the Re ing Jc<larations: UVJ
p]Ihave and will maintain aCertificamof Consemm self-insure for Worker's Compen- DRAINS-FLOOR.ROOR ARI-.A. N ST'0 IF.5 TYPE CONSTRUCTION
sation,as provided for by Section 37M of the labor Calc,for me performance of the
work for which this permit is issued. FIXTURIS-PIER TRAP r^- /,vJ
I]1 have and will maintain Worker's Compensation Insurance,as repaired by Section .1
]1M of da,Labor=e:fdr the pe ,-Lp'''Ire of the work fmwhRh this permit is issued. GAS-IEA.SYSTEM-I INC.4 OUTI.1111 S DEC.GROUP �ajPA
My Worker'. �mpr mint Policy
Policy ggmbr GAS-EA.SYSTIEM OVER4(IS)
Cartiee Policy PRO
CE fIPoC TE OF E)EMPI'IDN FROM WO [ERS' Gftts51%INDUSTRL WASTE INTERCEPTOR '
COMPENSATION INSURANCE BUILDING DIVISION PERS
(This section neednat be completed ifihmi
epert is forone hundred diarmv($100) GREASHTRAI'
or let,.) 1'LANCIIf:CK IEE
Al- los-
Immythmirithe perforneaneeofthework fmwhichthispemtit isissued.[shall SEWER-SAN]'T'ARY-STORM EA.200 RI'.
not employ any parsoin any mnn
aer u+as m became objecta i the WorkerR pe
Comn- ENERGY I§EH 3 10
n
,Z Nation Laws of California.Date WNFPLMSA"ITER wivewrL'I.r.mR-.
Z Applicant ) GRADING FRE
(n NOTICE TO APPLICANT:If,after making this Cenificac of Exemption,you ebould WAI i S S'1'CM/fRP.A'1'ING
abecome subject to the Worker's Compensation provisions of the labor Code,you must SOILS FBI:
Lkl forthwith comply with such provisions or this pemut shall be deemed revoked. WA'1' :'.RVICC
Q
CONSTRUCTION LENDING AGENCY NEW DENTInLi'hMB.3 w;Q. PAID
U O l hereby affirm that there is a construction lending agency for the performance of ate Receipt
the.,,,it for which this permit is issued[Sec.31197,Civ.C.)
Lendees Name '1'OI'AL:
Lender's Address T371'Ne /
I cenify that I have read thin application and cart thin the almvc infimnvtinn is _ ____ BUILDING
raA correct.l agree to comply win all city and county ordinances and state laws relating m QTY, CCI IANICAI,PERMIT FEE In,
U Z building construction,and hereby authorize reprcunmtives ofthis city to enter amen the SIEIRMIC O
cause-mentioned property for inspection purposes. 1'IiRMIT ISSUANCCIT. Q Q
(We)agree m save,indemnify and keep[incomes,the Chy of Culcrtino aguinet ELECTRIC
liabilitiesjudgments,cusp and expenses which may in anyway acemeagremn said City AITHRORADUTOMIECE.
PLIIMBINr FEE
in Pof gaming of this pe WILL
APPLICANT
WI
UNDERSTANDS AND LL COMPLY WITH ALL NON-POINT Alit HANDLING Grit T(fO IQnW CIM)
MCCIIA .AI.ERIE
SOURCE RG z,f. � ��
- I//!e'I-a —)� AIR[IAN DLING UN l'I'(OVER I B,IXNI CPM) CONSTRUCT NTAX'
S+gnature of7iplicint/Co.orm, �7 Dam IiXHALS'I'HOOD(W/DUC'q IIOUSING MI FI TION PI3E
I IA'LARDOUS MATERIALS DISCLOSURE'
Will the applicant or future building occupant sero or handle hazardous material I IHATI NO UNIT(TO 101,000 BTO)
as defined by the Cuporum,Municipal Code.Chapter 9.12,and the health and Safety
Code,Section 25532(x)1 1112AT'INC,I1NI'f(OVER IIX1,IxX1 IfI'I p
❑Vex ❑No VIENfI LAU ON PAN(SINGLE RES I U) PAID
Will the applicant lumre u
bilding occppvnt um eyuipmenl nr devices which
+ BOILER-COMP(31111 OR I Ig11XX)B'f(l)
mit hazardous air contaminants as defined by the flay Area Air Quality Monnt
rgecre O.
District,
2 Ycs El Nn BOILER-COMI'IOVI?It IINI,IIIXI Ii'1'll)
I have read the hnzmdme,moarntiN rcynarmem,under Chapter fi95 of the Culi- Alit CONDI'[TONiER ISSUANCE DATE
forma Ilealth&Safety Cale,Sections 25505,25533 and 25534,'1 undersand[hal if he NIEW RRSIDIEMf1AL MIECIL SQ.FB 3 .--
building doe.,nm turcndy hove a mnvnt,mm it is my rosponsihiliD m nmiry the rccuptnm O
ofiherequ' mr;ls air mel ainrm issuaamofu Celiicmc of Ocruienuy.
Go, n Dow TOTAL: ISSUED BY:
OFFICE ��